Summertime, and the livin' is ... dangerous. Most children are
home from school, and many zip along sidewalks and streets on bicycles,
skateboards and in-line skates. So, too, do newly licensed teenagers
and, presumably, seasoned drivers cruise the roadways. Accidents happen.
And the result is often more than a sprained wrist or ankle.

The National Pediatric Trauma Registry in the United States tracks
data on the more than 80,000 children who sustain trauma each year.
According to Ronald Savage, an expert in traumatic brain injury (TBI),
just as many children recorded in this databank sustained traumatic
brain injury as fractures.

How many children suffer head trauma? A lot! Published estimates
place the incidence of significant head trauma between 200 and 300 per
100,000 children and adolescents, or between 54,000 and 81,000 per year
in the US. That number is probably even higher since symptoms of brain
injury are similar to other categories in special education that are
more familiar to school personnel. Many children with TBI are
incorrectly classified by registries or databanks in special education
as being learning disabled, developmentally disabled, emotionally
disturbed or as having attention deficit hyperactivity disorder.

The term "traumatic brain injury" refers to a specific
type of disability that occurs after birth (usually, but not always, due
to accident or abuse); in fact, it is sometimes referred to as
"acquired brain injury," as opposed to something with a
genetic or "unknown" cause.

The consequences of TBI depend heavily on the type of injury, on
the part of the brain where the injury occurred and on the age of the
child. At one time it was assumed that children would recover better and
more quickly if the accident occurred in early childhood, in the belief
that brain plasticity would aid in recovery. Now it is recognized that
younger children, ages birth to five years, have a more difficult time
recovering because their brains are injured during a period of rapid
brain growth and maturation. Indeed, since older adolescents and young
adults have simply had a longer time living and coping with daily
events, they have more practical knowledge and experience to help
compensate for an injury to the brain. This new knowledge makes the fact
that the majority of brain injuries occur in children under the age of
10 even more cause for concern. Incidentally, twice as many boys as
girls sustain a traumatic brain injury.

What are some of the common causes of TBI? The national registry on
brain injury, mentioned above, reports that most pediatric TBI injuries
result from motor vehicle collisions (27.1%) and falls (26.5%), like the
one Jack, and so many others in classic nursery rhymes, took. Yet the
number of brain injuries resulting from bicycle accidents (9.7%) or
sports (5%) is also daunting. In an infant TBI is usually due to either
child abuse or a fall.

Do certain activities place a child at risk? Despite their
propensity to recover skills more quickly, older children and youth are
more likely to engage in sports, a widespread risk factor for head
injury. In the old days, coaches and even parents were quick to dismiss
head injuries as "bell ringers" or just as part of the game.
Today we are well aware that playing sports can carry a risk of
concussion, a mild form of brain injury. Football is not solely to
blame, although it is certainly the main culprit. High risk is also
associated with ice hockey, rugby, martial arts, soccer and horseback
riding.

James Kelly and Ronald Savage have written eloquently about how
best to evaluate concussions in sports, whether--or when--the athlete
should re-enter the sport, and what parents and educators should be
aware of when the athlete returns to play. Their report draws on data
from the Centers for Disease Control and Prevention estimating 300,000
sports-related concussions in the US each year.

Kelly and Savage provide explicit guidelines for determining
whether to return an athlete, or a child, to the game. For example,
according to their guidelines, after a grade 1 or mild concussion, an
athlete can be returned to play only if he or she is symptom-flee at
rest, or symptom-free with exertion within 15 minutes of the injury. In
a grade 2 or moderate concussion, the individual should refrain from
sports for at least a week. In a grade 3 concussion, which is the most
severe, there is typically a loss of consciousness; thus, return to play
should occur after a minimum one-month recovery. However, there are
exceptions and caveats even to these guidelines, allowing more or less
rest and recommendations for follow-up examination.

In an extensive review of neuropsychology's contribution to
understanding brain injury during sports, Ruben Echemendia and Laura
Julian propose that neuropsychological tests may be more useful than
traditional neuroimaging techniques because they can detect subtle
losses in an athlete's attention and concentration. Echemendia and
Julian also note that these traditional neuroimaging techniques, such as
computerized tomography (CT) and magnetic resonance imaging (MRI), may
not detect abnormalities, even when the injured child or his parents
report somatic complaints or cognitive impairment following the
concussion.

Most parents (and educators and coaches for that matter) are not
aware of post-concussion syndrome, which refers to repeated concussions
over an extended period of time. Obviously, the more frequent the
concussions, the greater the likelihood that there will be neurological,
cognitive and/or behavioral deficits in the child or young adult.

It is important that parents, teachers and other professionals who
work with the child monitor his or her cognitive, behavioral and
physical changes for six to eight weeks following an injury.
Fortunately, with a first injury, no permanent negative effect is
likely, and full recovery of the injured child is expected. But, because
a child active in sports can have four or more different coaches during
high school, parents must be responsible for being aware of their
child's injury history and making sure each new coach is also kept
apprised.

Does a child's "special need" immunize him at all
from further traumatic brain injury? Sadly, no. In fact, some children
with special needs are at even higher risk for injury than children in
the general population. For example, children whose behavior is
characterized by inattention, impulsivity, hyperactivity, highly
disturbed reactions, aggression, irritability and/or depression are less
likely to be tuned into what is going on around them. They are more
likely to engage in risky or careless behaviors--such as stepping in
front of a moving vehicle--which can lead to injury.

Researcher Jenny Sherrard and her colleagues in Australia recently
published results of a large-scale study on injury risk in about 500
young people ages 4 to 18 years with an intellectual disability. The
investigators used data collected across two time periods five years
apart, which allowed them to calculate risk factors over time. Parents
answered questionnaires about the child's development and behavior
and about family functioning and economic status. The authors identified
three risk factors highly associated with injury: having epilepsy, which
increases the likelihood of falls; having clinically significant levels
of behavioral or emotional problems; and having an overly sociable
temperament (e.g., attempting more risky activities without a full
understanding of the consequences). Clearly, acquiring a brain injury in
addition to another disability constitutes a double-whammy for both the
child affected and his parents.

How is the family affected by a traumatic brain injury? The
caretaking environment provided by parents, the extent of family
involvement in rehabilitation, overall family functioning and the
appropriateness of a child's educational program upon re-entry to
school are all paramount in determining the long-range impact of TBI.
Several recent studies by a team of researchers at Case Western Reserve
University and Ohio State University (led by H. Gerry Taylor, Keith O.
Yeates and colleagues) report on both short- and long-term outcomes for
children with TBI. In all cases, children who have moderate or severe
TBI and were from socially advantaged homes (whereby parents have higher
incomes, more resources and, potentially, fewer family stressors related
to the parents' health or work) had lower risk of depression and
lower rates of other new psychiatric disorders following injury. These
studies determined that "environmental advantages" are
critical for predicting positive outcomes in children after injury.

Furthermore, siblings seem to adjust well to having a brother or
sister with a serious TBI, as reported in a study by Mary McMahon and
her colleagues. These researchers hypothesized that siblings of affected
children might have more "acting out" or behavior problems, as
well as more "acting in" problems, such as depression or poor
self-concept. However, their studies found that there were no
significant differences in these areas when, 3 to 18 months after the
original injury, the siblings were compared to their classmates. With
only 12 siblings involved, this was a small, but clinically useful
study. Is this really good news? You bet--because parents can be in
control of providing a positive and supportive family environment for
both the child with the TBI and any siblings.

Is it possible to pick up all the pieces after a traumatic brain
injury? It is heartening to know that rapidly developing technology can
better detect brain abnormalities and pinpoint areas of
functioning--such as social skills, the management of emotions,
mathematical processing and reading--that might be negatively affected.
At a more practical level, rehabilitation and education efforts have
also advanced, and there is growing awareness of TBI among public school
personnel. Promising interventions used successfully with children with
learning or cognitive disabilities also seem to work with TBI. For
example, "self-monitoring" techniques taught to children with
TBI have proven effective for increasing on-task behavior, task accuracy
and even improving social skills. If Humpty Dumpty had lived today, it
is likely that the neurosurgeons, psychologists, rehabilitation
specialists and special education teachers would be pretty successful in
putting him back together again.

A list of studies referred to in this Research Reflections may be
obtained by e-mailing requests to: epedit@aol.com.

Dr. Jan Blacher is a Professor in the School of Education at the
University of California, Riverside, where she has been a researcher for
more than 25 years. She is currently the principal investigator of the
UC Riverside Families Project, a study of families of children with
severe disabilities. Over 600 families have been involved in the
Families Project research; their participation has contributed to our
knowledge about family coping, the cultural context of retardation, dual
diagnosis and the transition to adulthood. Dr. Blacher has developed
Research Reflections as a forum for communicating exclusively with
parents. The purpose of this column is to provide "news you can
use." She is eager to read your reactions to Research Reflections
and any suggestions you might have. Send e-mail to: jan.blacher@ucr.edu.

COPYRIGHT 2002 EP Global Communications, Inc.
No portion of this article can be reproduced without the express written permission from the copyright holder.